Showing papers in "Canadian Journal of Anaesthesia-journal Canadien D Anesthesie in 2008"
TL;DR: In hip fracture patients, operative delay beyond 48 hr after admission may increase the odds of 30-day all-cause mortality by 41% and of one-year all- cause mortality by 32%.
Abstract: Purpose: Mortality associated with hip fracture is high in elderly patients. Surgical repair within 24 hr after admission is recommended by The Royal College of Physicians’ guidelines; however, the effect of operative delay on mortality remains controversial. The objective of this study was to determine whether operative delay increases mortality in elderly patients with hip fracture.
561 citations
TL;DR: Complications of transesophageal echocardiography are primarily related to the gastrointestinal, cardiovascular, and respiratory systems, and include infection, toxic drug reaction, local reaction through contamination of the probe, and ultrasound cavitation.
Abstract: Purpose: The use of transesophageal echocardiography has increased over the past several years. It is generally considered a safe diagnostic and monitoring tool. Whereas complications associated with echocardiographic examination rarely occur, such complications must be known to echocardiographers performing these examinations. The purpose of this review is to summarize potential complications associated with transesophageal echocardiography. Sources: A systematic search of the English and French literature was undertaken using PubMed from the National Library of Medicine. Relevant articles were obtained from a Medline search spanning the years 1975 – 2007, and their reference lists were used to retrieve additional articles. Principal findings: Complications of transesophageal echocardiography are primarily related to the gastrointestinal, cardiovascular, and respiratory systems, and include infection, toxic drug reaction, local reaction through contamination of the probe, and ultrasound cavitation. Strategies to prevent these complications are reviewed. Conclusion: Whereas transesophageal echocardiography is associated with a low complication rate, the echocardiographer must be knowledgeable about the types of complications and their predisposing factors, and should be meticulous in preventing their occurrence.
101 citations
TL;DR: Intraoperative lidocaine infusion reduces opioid consumption in the postanesthesia care unit (PACU) and intraoperative requirements of desflurane.
Abstract: Background: Lidocaine has been shown to inhibit neural conduction and to have anti-inflammatory properties. The purpose of this study was to determine whether intraoperative lidocaine infusion reduces opioid consumption in the postanesthesia care unit (PACU).
100 citations
TL;DR: Transcranial Doppler ultrasonography can be useful pre- and post-operatively, while helping to recognize the development of cerebral vasospasm before the onset of its clinical effects, and has become a regularly employed tool in neurocritical care and perioperative settings.
Abstract: Purpose: To review the literature regarding the use of transcranial Doppler ultrasonography (TCD) for monitoring cerebral vasospasm following subarachnoid hemorrhage (SAH). Source: We searched Medline (1980 to August 2007) and Embase (1980 to August 2007) and reviewed all relevant manuscripts regarding TCD and SAH. Principal findings: Currently, the gold standard for vasospasm diagnosis is cerebral angiography, replaceable by computed tomography angiography, only when angiography is not available. Obviously, it is not feasible to perform such investigation as frequently as bedside clinical assessment. Repeated clinical assessments of a patient’s neurological status carry the problem of detecting the clinical signs and symptoms of vasospasm, which occur only after vasospasm has already manifested its deleterious effects on the cerebral parenchyma. Transcranial Doppler ultrasonography is a relatively new, non-invasive tool, allowing for bedside monitoring to determine flow velocities indicative of changes in vascular calibre. Transcranial Doppler ultrasonography can be useful pre-, intra- and post-operatively, while helping to recognize the development of cerebral vasospasm before the onset of its clinical effects. Conclusion: Vasospasm following SAH is a very important source of morbidity and mortality. Too often, the first sign is a neurologic deficit, which may be too late to reverse. Transcranial Doppler ultrasonography assists in the clinical decision-making regarding further diagnostic evaluation and therapeutic interventions. When performed in isolation, the contribution of TCD to improving patient outcome has not been established. Nevertheless, TCD has become a regularly employed tool in neurocritical care and perioperative settings.
85 citations
TL;DR: It is concluded that xenon, in the infant mouse brain, has paradoxical properties: it triggers neuroapoptosis, and when combined with isoflurane, it increases the depth of anesthesia, and retains its own apoptogenic activity.
Abstract: Purpose: Drugs that suppress neuronal activity, including all general anesthetics that have been tested thus far (ketamine, midazolam, isoflurane, propofol, and a cocktail of midazolam, nitrous oxide and isoflurane), trigger neuroapoptosis in the developing rodent brain. Combinations of nitrous oxide and isoflurane, or ketamine and propofol, cause more severe neuroapoptosis than any single agent by itself, which suggests a positive correlation between increased levels of anesthesia and increased severity of neuroapoptosis. In contrast, there is evidence that the rare gas, xenon, which has anesthetic properties, protects against isoflurane-induced neuroapoptosis in the infant rat brain, while not inducing neuroapoptosis by itself. The present study was undertaken to evaluate the potential of xenon to induce neuroapoptosis or to protect against neuroapoptosis induced by isoflurane in the infant mouse brain. Methods: Seven-day-old C57BL/6 mice were exposed to one of four conditions: air (control); 0.75% isoflurane; 70% xenon; or 0.75% isoflurane +70% xenon for four hours. For histopathological evaluation of the brains, all pups were euthanized two hours later using activated caspase-3 immunohistochemical staining to detect apoptotic neurons. Under each condition, quantitative assessment of the number of apoptotic neurons in the cerebral cortex (CC) and in the caudate/putamen (C/P) was performed by unbiased stereology. Results: The combination of xenon + isoflurane produced a deeper level of anesthesia than either agent alone. Both xenon alone (p<0.003 in CC;p<0.02 in C/P) and isoflurane alone (p<0.001 in both CC and C/P) induced a significant increase in neuroapoptosis compared to controls. The neuroapoptotic response to isoflurane was substantially more robust than the response to xenon. When xenon was administered together with isoflurane, the apoptotic response was reduced to a level lower than that for isoflurane alone (p<0.01 in CP; marginally non-significant in CC). Conclusions: We conclude that xenon, in the infant mouse brain, has paradoxical properties. It triggers neuroapoptosis, and when combined with isoflurane, it increases the depth of anesthesia, and retains its own apoptogenic activity. However, it suppresses, rather than augments, isoflurane’s apoptogenic activity.
83 citations
TL;DR: Successful implementation of medical emergency teams (MET) reduces patient morbidity and ICU resource utilization and may possibly reduce cardiac arrests, postoperative complications, and hospital mortality.
Abstract: Purpose: Medical emergency teams (MET) merge earlier-thanconventional treatment of worrisome vital signs with a skilled resuscitation response team, and may possibly reduce cardiac arrests, postoperative complications, and hospital mortality.
81 citations
TL;DR: The Bonfils intubation fibrescope is a more effective intubating device for patients with immobilized cervical spine and significantly limited inter-incisor distance, when compared to direct laryngoscopy.
Abstract: Background: The Bonfils intubation fibrescope (BIF), a rigid, straight and reusable fibreoptic device, is being used increasingly to facilitate endotracheal intubation after direct laryngoscopy has failed. We tested the hypothesis that, with the BIF compared to direct laryngoscopy, the rate of failed endotracheal intubation could be reduced in patients with a difficult airway, simulated by means of a rigid cervical immobilization collar. Methods: Seventy-six adults undergoing elective gynecological surgery under general anesthesia were randomly assigned to have endotracheal intubation, facilitated with either a standard size 3 Macintosh laryngoscope blade, or the BIF. A rigid cervical immobilization collar was used to simulate a difficult airway, by reducing mouth opening and limiting neck extension. If endotracheal intubation could not be achieved within two attempts, the cervical collar was removed, and direct laryngoscopy was performed thereafter, using a Macintosh blade in all subjects. The success rate of endotracheal tube placement was the primary outcome variable. Results: Patient characteristics were similar in the two groups. After neck immobilization, the inter-incisor distance was reduced to 2.6±0.7 cm (Macintosh) and 2.6±0.8 cm (BIF). Tube placement was successful in 15/38 (39.5%) patients with a Macintosh blade, and in 31/38 patients with the BIF (81.6%;P=0.0003). Time required for tube placement was 53±22 sec (Macintosh) and 64±24 sec (BIF;P=0.15). Conclusion: The Bonfils intubation fibrescope is a more effective intubating device for patients with immobilized cervical spine and significantly limited inter-incisor distance, when compared to direct laryngoscopy.
70 citations
TL;DR: The results support the use of TEA in this group of patients and reduce postoperative pain and atelectasis and improves pulmonary function in patients undergoing CABG surgery.
Abstract: Purpose: Pulmonary dysfunction commonly occurs following coronary artery bypass graft (CABG) surgery, increasing morbidity and mortality. We hypothesized that thoracic epidural anesthesia (TEA) would improve pulmonary function and would decrease complications in patients undergoing CABG surgery.
66 citations
TL;DR: This narrative review summarizes the evidence derived from randomized controlled trials (RCTs) offering blinded assessment and sample size justification, in order to determine the benefits associated with adjunctive ultrasonography (US) and stimulating perineural catheters for nerve blocks.
Abstract: Purpose: This narrative review summarizes the evidence derived from randomized controlled trials (RCTs) offering blinded assessment and sample size justification, in order to determine the benefits associated with adjunctive ultrasonography (US) and stimulating perineural catheters for nerve blocks Source: The literature search for this review was conducted during the second week of December 2007 using the MEDLINE (January 1950 to November 2007) and EMBASE (January 1980 to November 2007) databases For US-guided peripheral and neuraxial blocks, the following medical subject heading (MeSH) terms were searched: “nerve block”, “epidural anesthesia”, “epidural analgesia”, “epidural injection”, “epidural space”, “spinal anesthesia”, and “spinal injection”, the results were combined with “ultrasonography” (MeSH term) and “ultrasound” (key word) For stimulating perineural catheters, the following MeSH terms were cross referenced with the MeSH term, “nerve block”: “peripheral catheterization”, “indwelling catheterization”, “catheterization”, and keywords, “nerve catheter” and “continuous” Subsequently, the result of this search was combined to “stimulating” (key word) Fifteen RCTs, offering blinded assessment and sample size justification, were retained for analysis Principal findings: For axillary blocks, US guidance yields a higher success rate than a double-injection, transarterial and a triple-injection, neurostimulation-guided technique Compared to a quadruple-stimulation technique, no major differences can be found The addition of nerve stimulation to US guidance offers no clear benefits for axillary blocks For femoral blocks, compared to neurostimulation, echoguidance is associated with a local anesthetic (LA) sparing effect (up to 42%) In children, US guidance yields a LA sparing effect and a longer duration of action for lower extremity nerve blocks Compared to their blind counterparts, stimulating catheters seem to offer limited clinical benefits Despite providing a sparing effect on LA and opioid consumption, stimulating catheters are not associated with a decrease in side effects or analgesia-related expenditures Conclusions: Published reports of RCTs provide evidence to formulate limited recommendations regarding the use of adjunctive US and stimulating perineural catheters Further well-designed and meticulously executed RCTs are warranted
61 citations
TL;DR: Pre-emptively administered gabapentin, 1200 mg, does not reduce the incidence, or the severity, of post-thoracotomy shoulder pain in patients receiving thoracic epidural analgesia.
Abstract: Purpose: Despite adequate epidural analgesia, up to 97% of patients undergoing thoracotomy experience ipsilateral shoulder pain In this setting, this study evaluated the safety and the efficacy of pre-emptive gabapentin
55 citations
TL;DR: In children undergoing IPPV with neuromuscular blockade, the size 2 PLMA is associated with a higher leak pressure by auscultation and less gastric insufflation compared to the CLMA and the improved fibreoptic view of the larynx through the PLMA may be advantageous for bronchoscopy.
Abstract: Purpose: To determine whether a functional difference exists between the size 2 laryngeal mask airway (LMA)-Classic™ (CLMA) and LMA-Proseal™ (PLMA) in anesthetized children who have received neuromuscular blockade. Airway leak during intermittent positive pressure ventilation (IPPV) and adequacy of fibreoptic laryngeal view were the primary study outcomes.
TL;DR: Methods to improve recruitment are required to enhance the feasibility of conducting a multicentre fluid resuscitation trial in early septic shock, and resuscitation algorithms were acceptable to most physicians.
Abstract: Background: It is unknown whether fluid resuscitation with colloid or crystalloid in patients with severe sepsis or septic shock is associated with an improvement in clinical outcome. This randomized controlled trial determined the feasibility of conducting a large trial testing resuscitation with pentastarchvs normal saline in early septic shock, powered for a difference in mortality.
TL;DR: The results demonstrate that TEG measures, performed on citrated blood samples, yield results that are consistent with a hyperocoagulable state.
Abstract: Purpose: Thromboelastography (TEG) evaluates the viscoelastic properties of whole blood to assess clot formation and hemostasis. When blood cannot be analyzed immediately, it is stored in citrated tubes to be analyzed after recalcification. In this study, we evaluated the results of TEG analysis performed on citrated blood and compared these results to values obtained from activated (kaolin and tissue factor) and non activated, fresh blood samples, obtained at various time intervals (one, two, and three hours).
TL;DR: The results suggest that US-guided AXB may improve block success, reduce the local anesthetic volume used, and shorten the time spent in the block room compared to traditional nerve localization techniques.
Abstract: Purpose: Ultrasound (US) is being used increasingly to guide needle placement during axillary brachial plexus blockade (AXB). This retrospective study investigated whether US guidance can increase the success rate, decrease block onset time, and reduce local anesthetic (LA) volume for AXB compared to a traditional (TRAD) approach, namely, peripheral nerve stimulation (PNS) and transarterial (TA) techniques. Methods: The anesthetic records, operative reports, discharge summaries, and surgical consultation notes of all patients who had undergone AXB for surgical anesthesia at the Toronto Western Hospital, between October 2003 and November 2006 were, retrospectively reviewed for evidence of block success and associated complications. Block success was defined as the achievement of surgical anesthesia without additional LA supplementation. Results: Among the 662 patients, 535 patients underwent AXB using US guidance (US group), and 127 using TRAD techniques (TRAD group), namely, 56 using PNS (PNS subgroup) and 71 using the TA technique (TA subgroup). The block success rate was higher in the US group compared to the TRAD group (91.6%vs 81.9%,p=0.003). The LA volume used for AXB was less in the US group compared to the TRAD group (39.8±6.4 mLvs 46.7±17.1 mL,p<0.0001). Ultrasound group patients spent less time in the block procedure room than those in the TRAD group (30.6±14.2 minvs 40.1±27.3 min,p<0.0001). When analyzed by subgroup, the US group demonstrated significantly greater success and shorter duration in the block room compared to the PNS subgroup, but not the TA subgroup. Complications (inadvertent intravenous LA injection, and transient neuropathy) were lower in the US group compared to the TRAD group (0.37%vs 3.15%,p=0.014). Conclusions: Our results suggest that US-guided AXB may improve block success, reduce the local anesthetic volume used, and shorten the time spent in the block room compared to traditional nerve localization techniques.
TL;DR: The results suggest that simulator-based, task-orientated time measurement may not be a good indicator of FOI performance in the clinical setting.
Abstract: Purpose: Simulation centres, where trainees can practise technical procedures on models of varying fidelity, provide a training option that allows them to acquire skills in a controlled environment prior to clinical performance. It has been proposed that the time to complete a simulator task may translate to proficiency in the clinical setting. The objective of this study was to determine whether time to complete a simulator task translates to clinical fibreoptic manipulation (FOM) performance.
TL;DR: A case of autonomic, neurological and neuromuscular instability following methylene blue infusion for parathyroidectomy and the argument for a diagnosis of serotonin syndrome is reported, suggesting an interaction between methyleneblue and serotonergic agents may give rise to the serotonin syndrome.
Abstract: Purpose: To report a case of autonomic, neurological and neuromuscular instability following methylene blue infusion for parathyroidectomy; to advance the argument for a diagnosis of serotonin syndrome; and to consider this diagnosis in previous, unexplained reports of adverse reactions amongst patients undergoing parathyroidectomy using methylene blue. Clinical features: Methylene blue was administered to a 58-yr-old woman undergoing a parathyroidectomy under general anesthesia. The patient had a background of obsessive compulsive disorder treated with paroxetine. Postoperatively, she demonstrated symptoms and signs of serotonin syndrome; specifically tachycardia, agitation, dystonia and abnormal eye movements. These clinical findings spontaneously resolved themselves over the subsequent 48 hr. Conclusion: An interaction between methylene blue and serotonergic agents may give rise to the serotonin syndrome. Consideration should be given to avoiding methylene blue in patients taking serotonergic agents. The diagnosis should be considered in patients with autonomic, neuromuscular or neurological changes and should be managed accordingly.
TL;DR: Following induction of anesthesia with propofol and moderate-dose remifentanil, cisatracurium did not confer a higher rate of good-to-excellent conditions for tracheal intubation, nor did muscle relaxation with cisatacurium decrease the rate of SLI after tracheAL intubating.
Abstract: Purpose: The need for muscular relaxation to improve intubat-ing conditions and to reduce the incidence of laryngeal morbidity is still controversial. The aim of this study was to determine the incidence of symptomatic laryngeal injuries (SLI) and of acceptable intubating conditions (including both good and excellent conditions), both with and without cisatracurium during induction of anesthesia, along with moderate doses of remifen-tanil and propofol. Methods: In this prospective, randomized double-blind equivalence trial, the intubating conditions were compared in 130 ASA I or II female patients. All subjects received remifentanil 2 µg·kg−1iv and propofol 2.5 mg·kg−1iv, with either cisatracu-rium 0.15 mg·kg−1iv (group Cisatracturium), or saline (group Placebo). Tracheal intubating conditions were assessed with the Copenhagen Score. A systematic screening for postoperative hoarseness and sore throat was performed 24 and 48 hr after anesthesia, followed by a nasofibroscopic examination when laryngeal symptoms persisted at 48 hr. Results: Twenty-four hr after anesthesia, the incidence of postoperative hoarseness and sore throat in the Cisatracurium and Placebo groups was 26.5% and 21.5%, respectively, and 48 hr after anesthesia, the incidence was 7.8% and 6.1%, respectively (P=0.32 andP=0.50 between groups, respectively). In the clinically evaluable population, the incidence of SLI, assessed at 48 hr by nasofibroscopy, was equivalent in both groups, 1.6%vs 1.5% in group Placebo and group Cisatracurium, respectively (P<0.001 for equivalence test), as was the occurrence of acceptable intubating conditions (95.4%vs 100%,P<0.05 for equivalence test). However, the occurrence of excellent intu-bating conditions was more frequent in group Cisatracurium than in group Placebo (P=0.0003). Conclusion: Following induction of anesthesia with propofol and moderate-dose remifentanil, cisatracurium did not confer a higher rate of good-to-excellent conditions for tracheal intubation, nor did muscle relaxation with cisatracurium decrease the rate of SLI after tracheal intubation.
TL;DR: Excessive demands for postoperative intravenous-PCA morphine during lockout intervals appear to reflect, in part, poor preoperative adaptation to surgery involving intrusive thoughts and avoidant behaviours about the upcoming surgery.
Abstract: Background: Psychosocial factors governing the use of postoperative, intravenous patient-controlled analgesia (PCA) have received little attention in spite of the fact that PCA is the most common modality for managing pain after surgery. The motivation behind requests for analgesia during lockout periods is not known. Unrelieved pain and need for pain medication are obvious reasons but other factors may be involved. The aim of the present study was to predict PCA lockout interval demands based on preoperative psychosocial factors.
TL;DR: Percutaneous retrograde aortic valve replacement is a novel procedure that presents the anesthesiologist with unique challenges, and careful preoperative assessment, intraoperative monitoring appropriate for a major vascular procedure, and meticulous management of hemodynamics are imperative for a successful outcome.
Abstract: Purpose: To describe both the evolution and the main associated complications in the anesthetic management of the initial 40 patients at our centre who underwent percutaneous retrograde aortic valve replacement, a novel technique utilizing a catheterguided femoral artery approach. Clinical features: With institutional Research Ethics Board approval, we retrospectively reviewed the medical records of the first 40 patients who underwent percutaneous retrograde aortic valve replacement between January 2005 and March 2006. Information obtained included patient characteristics, anesthetic management, details of the procedure, and complications. All procedures were scheduled to be performed in the cardiac catheterization laboratory. The first four patients received monitored anesthesia care, and the subsequent 36 underwent general anesthesia. There were no anesthesia-related adverse events. The prosthetic valve was placed successfully in 33/40 patients (83%). Median anesthetic time was 3.5 hr (range, 1.25–7.25 hr). Thirty-two/40 patients required vasopressor support. The most common, serious procedural complications were myocardial ischemia and arrhythmia following rapid ventricular pacing, hemorrhage from vascular injury secondary to the placement and removal of the large-bore sheath in the ilio-femoral artery, aortic rupture, and prosthetic valve maldeployment; 30-day mortality was 13% (n=5/40). Conclusions: Percutaneous retrograde aortic valve replacement is a novel procedure that presents the anesthesiologist with unique challenges. Careful preoperative assessment, intraoperative monitoring appropriate for a major vascular procedure, and meticulous management of hemodynamics are imperative for a successful outcome. Serious complications, including major hemorrhage from vascular injury as well as arrhythmia and myocardial ischemia following rapid ventricular pacing, must be anticipated and managed in an expeditious fashion.
TL;DR: F fluoroscopy, when readily available in the operating room, is a safe and useful technique to ensure proper ETT placement among the pediatric population.
Abstract: Purpose: To ensure that the endotracheal tube (ETT) is ideally placed for proper ventilation, radiographic confirmation of ETT placement is frequently used to supplement clinical examination in the intensive care unit setting. However, fluoroscopy rarely serves the same role during surgery, despite the fact that portable units are often present in the operating room. The purpose of this study was to ascertain the value of fluoroscopy in determining ETT malposition among the pediatric surgical population.
TL;DR: Spinal anesthesia can be effectively performed in patients with poliomyelitis and severe kyphoscoliosis, that has been treated with extensive Harrington instrumentation, and bedside ultrasound may be greatly beneficial in identifying the correct spinal interspace.
Abstract: Purpose: To describe the anesthetic implications, and management of a medically complex parturient, who presented for Cesarean delivery (CD). The patient had poliomyelitis complicated with severe kyphoscoliosis, which had been treated with extensive spinal surgery. We used ultrasound guidance to facilitate successful spinal analgesia and anesthesia. Clinical features: A 27-yr-old woman, with a history of poliomyelitis and moderate restrictive lung disease secondary to kyphoscoliosis, presented at 38 weeks gestation for elective CD because of cephalopelvic disproportion. The woman had Harrington rods in situ from the level of the second thoracic vertebra, to the level of the fourth lumbar vertebra. Ultrasound guidance enabled one intervertebral space to be visualized (L5-S1), 3 cm from the expected spinal midline, and spinal anesthesia was performed at this interspace without any complications. A healthy infant was delivered, and the mother recovered uneventfully. Conclusions: Spinal anesthesia can be effectively performed in patients with poliomyelitis and severe kyphoscoliosis, that has been treated with extensive Harrington instrumentation. To facilitate regional techniques in such patients, bedside ultrasound may be greatly beneficial in identifying the correct spinal interspace.
TL;DR: Vasopressin may be effective in the resuscitation of anesthetized patients, with hemodynamic instability associated with anaphylaxis resistant to epinephrine and alpha-agonists associated with a severe,allergic response to rocuronium.
Abstract: Purpose: To report the use of vasopressin to treat a patient who, after failing to respond to volume expansion and epinephrine administration, experienced an anaphylactic reaction to rocuronium.
TL;DR: The review supports that surgery and thrombolysis have both been demonstrated to enhance survival in patients with RHTE and PE, however, important patient, clot, and institutional considerations mandate that treatment for patients with TBE and PE be individualized.
Abstract: Purpose: Central venous catheters (CVC) are commonly used in critical care. While thrombosis is a well-recognized and frequent complication associated with their use, CVC-related thromboembolic complications, including pulmonary embolism (PE) and right heart thromboembolism (RHTE), occur less frequently and often evade diagnosis. Little information exists to guide clinicians in the diagnosis and management of CVC-related thromboembolic complications.
TL;DR: This systematic review suggests that smoking-cessation interventions initiated at the preoperative clinic can increase the odds of abstinence by up to 60% within a three- to six-month follow-up period.
Abstract: Purpose: To assess the efficacy of interventions offered to patients in the preoperative clinic to promote long-term (≥ three months) smoking cessation following surgery. Methods: We searched The Cochrane Library, MEDLINE, EMBASE and CINAHL for all randomized controlled trials (RCTs) on smoking-cessation interventions initiated in the preoperative clinic. Trial inclusion, quality assessment, and data extraction were performed independently by two authors. Standard meta-analytic techniques were applied. Results: Four RCTs (n=610 patients) were included in the review. Interventions included pharmacotherapy, counseling, educational literature and postoperative telephone follow-up. The follow-up period ranged between three to 12 months with only one RCT following up patients for τ one year. Two studies used biochemical methods to validate subjects’ self-reporting of smoking cessation at the follow-up assessment. Overall, the interventions were associated with a significantly higher cessation rate vs control at the three to six month follow-up period (pooled odds ratio: 1.58, 95% confidence interval (CI) 1.02–2.45,P value=0.01, 12=0%). The only trial with longer follow-up period (12 months), however, failed to show any significant difference between the intervention and control groups (odds ratio: 1.05, 95% CI 0.53–2.09,P value=0.88). Conclusion: This systematic review suggests that smoking-cessation interventions initiated at the preoperative clinic can increase the odds of abstinence by up to 60% within a three- to six-month follow-up period. To evaluate the possibility of longer abstinence, future trials with at least one-year follow-up are recommended.
TL;DR: The co-administration of SSRIs and fentanyl may precipitate serotonin toxicity, and Physicians should be vigilant of the features of serotonin toxicity developing in patients established onSSRIs.
Abstract: Purpose: To report a case of serotonin toxicity, presenting in the postoperative period, caused by an interaction between paroxetine (a selective serotonin reuptake inhibitor, SSRI) and fentanyl (a phenylpiperidine opioid). Serotonin toxicity precipitated by fentanyl is unusual and has not previously been described in combination with SSRIs in the perioperative setting. Clinical features: A 60-yr-old woman, established on paroxetine for depression, underwent excision of a chest wall myxofibrosarcoma and chest wall reconstruction. Fentanyl was administered for intraoperative and postoperative analgesia (1 mg intraoperatively, and 2.5 mg by infusion in the first 36 hr, postoperatively). She developed a vague affectation, intermittent agitation, bilateral hyper-reflexia, inducible clonus, and a period of hypertension, suggestive of serotonin toxicity. There was complete resolution after cessation of fentanyl and paroxetine. Conclusion: The co-administration of SSRIs and fentanyl may precipitate serotonin toxicity. There must be consideration of this unusual interaction when administering fentanyl to patients established on SSRIs. Physicians should be vigilant of the features of serotonin toxicity developing in such patients.
TL;DR: Charcot-Marie-Tooth disease is a demyelinating, hereditary, motor and sensory neuropathy characterized by abnormalities of nerve conduction, and these cases show that ultrasound guidance makes peripheral nerve block possible in patients for whom traditional methods of nerve localization fail.
Abstract: Purpose: To describe the clinical presentation of three patients with Charcot-Marie-Tooth disease, who underwent uneventful upper limb surgery following successful peripheral nerve blockade, and to review the anesthetic implications in patients with Charcot-Marie-Tooth disease.
TL;DR: The combination of perioperative intravenous FA, intraoperative thoracic epidural anesthesia, and postoperative PCEA facilitated recovery of bowel function, enhanced analgesia, and attenuated the cytokine response after open colorectal surgery.
Abstract: Purpose: Flurbiprofen axetil (FA) is a potent non-steroidal antiinflammatory drug (NSAID). We examined the effects that perioperative intravenous administration of FA, combined with thoracic epidural anesthesia and postoperative patient-controlled epidural analgesia (PCEA), have on bowel function, postoperative pain, and cytokine release, after open colorectal surgery. Methods: This was a prospective, randomized, double-blind, placebo-controlled study. Forty patients were randomly assigned to one of two groups (n=20 in each group). The FA group patients received FA 1 mg·kg−1iv, 30 min before and six hours after skin incision; whereas the control group patients received an equal volume of intralipid. Blood cytokine levels were measured before FA administration, at the end of surgery, and six hours and 24 hr postoperatively. All patients received postoperative PCEA for pain control. Analgesic efficacy was evaluated for 72 hr postoperatively using visual analogue scale (VAS) pain scores both at rest and during coughing. Gastrointestinal motility was recorded. Temperature and leukocyte count were measured preoperatively, and 24 hr postoperatively. Results: The times to first bowel movement (87±23vs 105±19 hr,P=0.008) and first flatus (63±16vs 75±11 hr,P=0.01) were earlier in the FA group compared to the control group. For the first 24 hr, the pain scores in the FA group were also lower during coughing (P<0.001 compared to control). The plasma concentrations of interleukin (IL)-6 and IL-8 in the FA group were lower, postoperatively (P<0.01 andP<0.05, respectively, compared to control). In contrast, the IL-10 levels were significantly increased at six hours, postoperatively, in the FA group (P=0.009). The total leukocyte count and the incidence of pyrexia were also lower in patients of the FA group (P=0.001 0.001 andP=0.006, respectively, compared to control). Conclusion: Flurbiprofen axetil may have an anti-inflammatory effect in major abdominal surgery. The combination of perioperative intravenous FA, intraoperative thoracic epidural anesthesia, and postoperative PCEA facilitated recovery of bowel function, enhanced analgesia, and attenuated the cytokine response.
TL;DR: The data suggest that GSK-3ß play an important role in propofol cardioprotective actions during coronary reperfusion, but mitochondrial KATP channels do not.
Abstract: Purpose: Propofol exerts cardioprotective effects, but the involved mechanisms remain obscure. The present study examines the cardioprotective effects of propofol and its role in cardiac function, including its effect on KATP channel opening and the inhibition of GSK-3s activity in ischemia-reperfused hearts. Methods: Ischemia-reperfusion (I/R) was produced in isolated guinea pig hearts by stopping coronary perfusion for 25 min, followed by reperfusion. The hearts were incubated for ten minutes, with or without propofol (25 or 50 µM), or for five minutes with 500 µM 5-hydroxydecanoate (a mitochondrial KATP channel blocker) or 30 µM HMR1098 (sarcolemmal KATP channel blocker), followed by five minutes with 50 µM propofol before ischemia. Action potentials on the anterior epicardial surface of the ventricle were monitored using a high-resolution charge-coupled device camera system, and at five minutes after reperfusion, GSK-3s phosphorylation at the serine residue, Ser9, was examined. Results: After 35 min of reperfusion, propofol (25 and 50 µM) blunted the adverse effects of I/R and reduced infarct size (P<0.05). In addition, prior incubation with 5-hydroxydecanoate or HMR1098 had no effect on functional recovery improved by 50 µM propofol. At five minutes after reperfusion, propofol (25 and 50 µM) shortened the duration of the action potential and increased the levels of phospho-GSK-3s (P<0.05). Conclusions: Propofol enhanced mechanical cardiac recovery and reduced infarct size. The data further suggest that GSK-3s play an important role in propofol cardioprotective actions during coronary reperfusion, but mitochondrial KATP channels do not.
TL;DR: Cadavers may provide viable training options for practicing ultrasound imaging and real-time ultrasound needle guidance for nerve blocks at the trunk and epidural space and the training can be performed in a stress-free pre-clinical environment without time constraints and the potential for patient discomfort.
Abstract: Purpose: The unique strategy of using cadaveric models for teaching ultrasound-guided blocks has been described for blocks of the upper and lower extremities. This report considers the parallels between cadaveric and live imaging relevant to scanning of the trunk. The inter-individual variation between subjects (particularly for epidural blocks) is also considered, for practicing ultrasound-guided or supported trunk and central neuraxial techniques.